To help diagnose generalized anxiety disorder, your doctor or mental health The two main treatments for generalized anxiety disorder are. See your GP if anxiety is affecting your daily life or is causing you distress. Generalised anxiety disorder (GAD) can be difficult to diagnose. In some cases, it can. Generalized anxiety disorder (GAD) can be a challenge to diagnose. People consider panic attacks a hallmark of all anxiety disorders, and.
Disorder Diagnosing Anxiety
Anxiety is a normal reaction to stress that most people experience throughout their lives. A person may feel anxious when speaking in public, taking a test, or making an important life decision. But if the anxiety is more than temporary worry or fear, does not go away, or worsens over time, this may be a sign of an anxiety disorder.
NYU Langone specialists offer expert diagnosis of anxiety disorders, which are common mental health conditions that can interfere with daily activities, affecting your performance at work and school as well as your relationships.
If you experience any symptoms of an anxiety disorder , see your doctor or a mental health specialist, such as a psychiatrist, psychologist, or licensed clinical social worker.
To diagnose an anxiety disorder, a doctor performs a physical exam, asks about your symptoms, and recommends a blood test, which helps the doctor determine if another condition, such as hypothyroidism , may be causing your symptoms. Buspirone can also be used; it usually takes 3 to 6 weeks at a dosage of 10 to 20 mg three times daily to become effective. Compared with benzodiazepines, which can also be used to treat GAD, buspirone is not associated with dependence, withdrawal effects, or abuse.
The benzodiazepines can also be used for the treatment of GAD. They have a rapid onset and a somewhat favorable side-effect profile, but they are typically only recommended for acute anxiety reactions, and not for the treatment of chronic GAD. A panic disorder primarily consists of an intense fear or sense of impending doom that is intolerable and unbearable. Patients feel an intense terror or fear associated with the disorder. They are typically started at lower doses when compared with the doses that are used to treat depression because those doses can exacerbate the anxiety in patients with panic disorder.
The same low dosing regimen also applies to the use of TCAs because of their ability to exacerbate panic symptoms. The TCAs can be associated with cardiovascular complications, and the use of monoamine oxidase inhibitors can cause hypertensive crisis, so these agents are not frequently used. Benzodiazepines can be used in combination with TCAs or SSRIs during the initial phase of treatment for a panic disorder, as they are very effective, especially if a person is not responsive to other therapies, but this should be done with the understanding that it may not be effective for long-term use.
Antiseizure drugs were initially used for mood stabilization in mood disorders; however, their anxiolytic properties were quickly noted. Many agents in this drug class are being used in an off-label fashion to treat anxiety, especially gabapentin Neurontin, Pfizer and pregabalin Lyrica, Pfizer. All tricyclic antidepressants TCAs function as norepinephrine reuptake inhibitors, and several mediate serotonin reuptake inhibition as well.
Although several medications in this drug class are comparable in efficacy to the SSRIs or SNRIs for anxiety disorders, TCAs carry a greater number of adverse effects and are potentially lethal in an overdose. For this reason, TCAs are rarely used in the treatment of anxiety disorders. Hydroxyzine Atarax, Pfizer , mirtazapine Remeron, Organon , nefazodone Bristol-Myers Squibb , and atypical neuroleptic agents are commonly used to treat anxiety.
Hydroxyzine is indicated for anxiety and probably achieves anxiolysis by inhibiting the histamine H 1 receptor and the serotonin-2a receptor. During the s, mainstream psychological and pharmacological treatments of anxiety disorders were developed and tested, leading to an initial algorithm that is similar for all major anxiety disorders.
Adapted from Roy-Byrne, et al. Arch Gen Psychiatry ;62: None of the SSRIs has shown superiority to another. The choice of an SSRI is usually based on the side-effect profile, pharmacokinetic and pharmacodynamic properties, and potential interactions with coadministered medications. Several excellent reviews of SSRI therapies for anxiety disorders have been published.
Antidepressants with broader mechanisms of action i. The rationale for this practice is that these medications affect more than one neurotransmitter system and have some, albeit weak, meta-analytic data supporting their superiority in depression and OCD.
Few data have been published about what to do after the few initial steps of treatment, such as how long maintenance therapy should last. Based on clinical experience, we generally recommend continuing treatment until the patient has achieved marked symptom reduction for at least 6 months.
More research on this topic is needed. Further testing of combined treatments at the initial and later steps of the typical algorithm was subsequently performed. Atypical neuroleptic medications have shown even better evidence of efficacy in anxiety disorders, according to some placebo-controlled trials.
Patients and physicians need to be aware of adverse drug reactions. Because polypharmacy is becoming the rule rather than the exception, especially in complex and treatment-resistant anxiety, practitioners should be cognizant of potential drug—drug interactions.
Serotonin syndrome and neuroleptic malignant syndromes, although rare, should be kept in mind. Symptoms may include paresthesias, nonvertiginous dizziness, nausea, diaphoresis, and rebound anxiety. CBT has received the greatest amount of empirical support for the psychological treatment of anxiety disorders. Combining drug therapy and CBT has shown mixed results in favoring one approach over the other, depending on the type of anxiety disorder.
A review and meta-analysis approached the question of combination treatment over monotherapy or CBT in anxiety by hypothesizing that CBT would be more successful compared with medications; however, the medication held an advantage over CBT in depression. By contrast, patients with social anxiety disorder were more responsive to medication. The choice of medication or CBT, alone or in combination, is based on several variables, including the availability of a therapist; the affordability of CBT, which costs more than medication, especially if drugs are prescribed in primary care settings; and patient preference.
It is generally acknowledged that the treatment of anxiety disorders is suboptimal because of a lack of CBT therapists or the availability of affordable sessions. There is a great need to distill the essence of good therapy and to bring it into the primary care setting, with an emphasis on education and staff training.
Their work suggested that even self-administered treatment might be an effective addition to the CBT armamentarium. Although many treatments are effective for anxiety, not all of them can help everyone and not all of them are effective for all anxiety disorders. A simple phobia is easier to treat than a complicated case of PTSD. Relapse rates for CBT, compared with medication, are an understudied area, although our clinical experience suggests that CBT has a longer treatment effect if the patient continues to use the skills and tools learned in therapy.
CBT shares much in common with other more dynamically based forms of psychotherapy. A patient seeks help from an expert caregiver who treats the patient in a warm and nonjudgmental relationship in an attempt to help the patient function and feel better in a reality-oriented setting. The helping relationship is less emphasized in CBT as a curative factor, but it is considered important in building trust and support, serving as a springboard for patients to consider their erroneous beliefs and behaviors that cause them anxiety and fear.
The therapist often incorporates manuals or other psychoeducational materials and may propose daily homework to help the patient learn more adaptive ways to manage and reduce the alarm A , change irrational and dysfunctional beliefs B , and develop adaptive coping C mechanisms, often through exposure exercises. To the most appropriate extent possible, patients are taught the ABC model to help them understand the dynamic and reciprocal relationship among feelings, thoughts, and behaviors.
Motivational interviewing, which is used to help patients examine the cost—benefit ratio of their maladaptive thoughts and behavior, often increases compliance and, subsequently, effectiveness. Although beliefs are the linchpin, exposure to the anxiety-producing thought, image, or situation is often the essential CBT component for jogging the linchpin loose. This too is a dynamic process.
Cognitive restructuring techniques aimed at reducing catastrophic thinking help to diminish irrational or exaggerated thoughts, thereby allowing patients to become more willing to test those beliefs through exercises involving exposure. Exposure is the gradual and systematic presentation of the anxiety-inducing thought, image, or situation for a long enough time for patients to see that their anxious feelings can be decreased without engaging in avoidance or escape.
For example, a patient who is afraid of dogs might first be shown a picture of a dog, then stand across the street from a pet shop, and finally hold a dog in his or her arms. The patient would engage in each of these steps repeatedly and in a concentrated but not overwhelming way. Ideally, the patient would experience a gradual lessening of anxiety at each step before moving on to the next. The patient would experience the alarm being reduced, and the exaggerated belief that all dogs are dangerous could be modified to a more accurate belief that most pet dogs are not threatening.
The hoped-for outcome would be that the patient would no longer have a phobic avoidance of all dogs. A final emerging area in the evolution of CBT is the approach based on mindfulness acceptance. Mindfulness is a type of meditation that has been adapted from Buddhist psychology.
Acceptance and commitment therapy involves a mindful focus; many exercises are aimed at the meta-cognitive level to help patients perceive their thinking and subsequent anxiety to be separate from, and less identified with, their sense of self.
Anxiety-causing thoughts are to be observed and accepted, not to be struggled with and changed, as in more traditional CBT and Western psychological approaches.
At the same time, SSRIs antidepressants are increasingly used in primary care, and physicians in fact are the largest group of prescribers. This is a mixed blessing for several reasons:. This state of affairs may partly explain why psychiatrists are seeing more patients who are disenchanted with numerous failed attempts at pharmacotherapy. Another problem in primary care is a lack of understanding of behavioral strategies that result in low referral rates to mental health professionals.
There has been a trend toward developing comprehensive treatments for panic disorder to be delivered by primary care physicians. In one study, an algorithm was tested for the treatment of panic disorder.
In managing refractory anxiety, it is important to start with a re-evaluation of the patient, including the diagnosis; comorbidities; and the interplay of cognitive, stress-related, and biological factors. Inadequate coping strategies on the part of patients and their family members should be reviewed.
Doses and duration of the initial treatments should be assessed. After that, the treatment may progress to a combination of SSRIs with antiepileptic or atypical neuroleptic agents, especially if bipolar disorder or a psychotic disorder is suspected.
Although other forms of therapy have not demonstrated efficacy in anxiety disorders, they may be helpful for addressing personality issues in chronically anxious patients. Therapies for anxiety disorders, beyond combining conventional treatments, using off-label antiepileptic and antipsychotic agents, and introducing more intensive CBT programs, are mostly experimental.
Promising medications have included intravenous clomipramine, citalopram, and morphine. A handful of invasive therapies have emerged. These options may be considered after several off-label pharmacotherapy and psychotherapeutic approaches have failed or when significant functional impairment remains. They are typically reserved for the most treatment-resistant cases, typically those involving severe OCD.
Invasive treatments often target brain circuits implicated in the processing of fear and anxiety. Electroconvulsive therapy ECT involves the application of brief electrical impulses to the scalp to induce large-scale cortical neuronal discharges, eventually producing generalized seizure activity. Although ECT is effective in treatment-resistant mood disorders, data regarding its efficacy in anxiety disorders are limited. Initially developed as an antiepileptic treatment, vagal nerve stimulation VNS was used in psychiatric patients after sustained mood improvements were noted with this therapy.
This modality is not routinely used to treat anxiety, and evidence of its effectiveness in resistant anxiety disorders is limited. Focal magnetic stimulation of the scalp is used with the goal of invoking excitation or inhibition of cortical neurons. Repetitive transcranial magnetic stimulation rTMS is less invasive than ECT; anesthesia induction is not required, and rTMS does not elicit generalized seizure activity in the brain.
It also has the advantage of being able to target brain regions thought to be involved in anxiety disorders. The main limitations of rTMS include the inability to penetrate deeper brain structures implicated in OCD the caudate nucleus, thalamus, and anterior capsule fiber tracts or in panic disorder the amygdala, hippocampus, and anterior cingulate ; there is also a lack of specificity at the site of stimulation.
There is limited evidence for efficacy in treating OCD, although larger treatment effects have been reported by altering the stimulation site. A small study reported significant anxiety reductions in patients with generalized anxiety disorder GAD using a symptom-provocation task during functional magnetic resonance imaging fMRI to guide individual selection of the rTMS site.
Although psychosurgery has been used for various treatment-resistant anxiety disorders such as GAD, panic disorder, and social phobia, long-term follow-up studies in these patients have revealed adverse cognitive outcomes, including apathy and frontal lobe dysfunction. Several surgical approaches have been used, including anterior capsulotomy which targets the anterior limb of the internal capsule , anterior cingulotomy which targets the anterior cingulate and cingulum bundle , subcaudate tractotomy which targets the substantia innominata, just inferior to the caudate nucleus , and limbic leucotomy which combines anterior cingulotomy with subcaudate tractotomy.
Cingulotomy remains the most commonly used psychosurgical procedure in North America, probably because of its clinical efficacy as well as low morbidity and mortality rates. Postsurgical effects have included transient headache, nausea, or difficulty urinating. Patient outcomes cannot be fully assessed until at least 6 months to 2 years after the definitive procedure, suggesting that postoperative neural reorganization plays an important role in recovery.
Direct comparisons of each lesion approach within studies are rare. Overall, the long-term outcomes of these approaches have demonstrated significant therapeutic effects of each procedure. The major advantage of DBS over ablative surgery is the ability to adjust and customize neurostimulation.
Parameters can be optimized by a specially trained clinician during long-term follow-up. Several studies with blinded stimulation have been conducted with moderate-to-fair results. Batteries must also be periodically explanted and replaced. Stimulation-related side effects have been reported, including mood changes transient sadness, anxiety, euphoria, and hypomania , sensory disturbances olfactory, gustatory, and motor sensations , and cognitive changes confusion and forgetfulness.
These side effects are typically stimulation-dependent and disappear after the stimulation parameters are altered. During the s, many alternative treatment strategies for anxiety disorders emerged.
These treatments may be provided by alternative medicine practitioners within the scope of a health care model, such as acupuncture, homeopathy, Ayurvedic medicine, Reiki, and healing touch. Because of minimal FDA regulation and widespread over-the-counter availability, many of these same treatments are self-selected and used by patients. Herbs are the most commonly used complementary and alternative medicine CAM products and are particularly popular with those with psychiatric disorders.
Anxiety is one of the strongest predictors of herbal remedy utilization, and patients often use these treatments without the knowledge of their physician. Consequently, clinicians and pharmacists are advised to regularly monitor the full range of treatments used by their patients, including a thorough medication reconciliation of prescription and non-prescription products, herbs, and supplements at each visit.
Results of herbal trials for anxiety disorders have been mixed. The widespread use of Piper methysticum Kava for anxiolysis was curtailed by reports of hepatotoxicity, prompting government warnings and withdrawal of the product from the market in many Western countries. Despite a lack of data on efficacy, many patients continue to use CAM therapies, prompting a need to monitor use for potential interactions with prescription medications.
Milk thistle inhibits CYP3A4 and has the potential to increase levels of other medications metabolized by this pathway.
Although many patients with anxiety disorders experience symptom relief with treatment, residual symptoms still have an impact on everyday functions. Even subclinical anxiety can produce disability sometimes exceeding that seen in other severe mental illnesses. Yet there are few clear interventions or programs with a focus on rehabilitation and restoration of function in these patients.
Stress is an important factor in the emergence and maintenance of anxiety syndromes. Patients who need to return to the workforce can experience increased stress that in turn may cause re-emergence of the symptoms, again resulting in decreased productivity and even loss of employment.
More research is needed to address this problem. Anxiety disorders are treatable. Effective treatments have been developed, and algorithms have been refined. However, more work needs to be directed toward merging of our knowledge of the biological mechanisms of anxiety with treatment in order to more accurately predict and improve treatment response.
Dynamic models of anxiety—such as the ABC model—can be helpful in understanding the interplay between processes responsible for development and maintenance of the symptoms over time and between biological and psychological factors affecting them.
We need to learn how to better administer existing efficacious treatments in real-world health care environments, such as in primary care, and to inform the public via media outlets. We should continue to test alternative therapies for treating and preventing anxiety disorders and to help patients whose anxiety is resistant to conventional treatments.
All of these measures will enhance the care of patients with anxiety. Bystritsky reports that he has received honoraria, research grants, and travel reimbursements from AstraZeneca, Takeda, and Brainsway. Schi3man report that they have no financial or commercial relationships in regard to this article. This work was supported in part by a grant from the Saban Family Foundation. National Center for Biotechnology Information , U. Journal List P T v. Author information Article notes Copyright and License information Disclaimer.
Schiffman is Director of the Dual Diagnosis Program. Accepted Jul This article has been cited by other articles in PMC. Abstract Anxiety disorders are the most prevalent mental health conditions. Open in a separate window. Interplay Between Biological and Psychological Factors In order to treat an anxiety disorder effectively, clinicians should understand how these conditions emerge and which factors are involved in maintaining them.
Stress Stress also plays a major role in the pathology of anxiety disorders. Biological Factors Biological factors are of primary importance in anxiety disorders. How Anxiety Affects Neurotransmitters Neuronal circuits are governed by multiple neurotransmitter systems; the most extensive of these are gamma-aminobutyric acid GABA and glutamate.
Serotonin The primary serotonergic pathways originate in the raphe nuclei and project widely to numerous targets throughout the forebrain. Dopamine The principal dopaminergic pathways originate from the midbrain in the ventral tegmental area and substantia nigra, with projections to the cortex, striatum, limbic nuclei, and infundibulum. Norepinephrine Noradrenergic neurons originate primarily in the locus coeruleus in the pons and project widely throughout the CNS.
Glutamate Glutamate is the primary excitatory neurotransmitter in the CNS and is involved in virtually every neuronal pathway, including those underlying normal and pathological anxiety states. Other Neurotransmitters Many other neurotransmitter systems participate in the biological mechanisms of fear and anxiety. Selective Serotonin Reuptake Inhibitors SSRIs, usually indicated in depression, are considered to be the first line of therapy for anxiety disorders.
Serotonin—Norepinephrine Reuptake Inhibitors SNRIs, which inhibit the serotonin and norepinephrine transporters, include venlafaxine, desvenlafaxine Pristiq, Pfizer , and duloxetine. Benzodiazepines Although benzodiazepines were widely used in the past to treat anxiety conditions, they are no longer considered to be first-line therapies because of the risks associated with their chronic use. Antiseizure Medications Because of the side effects of benzodiazepines, antiepileptic agents have been used more extensively for the treatment of anxiety.
Tricyclic Antidepressants All tricyclic antidepressants TCAs function as norepinephrine reuptake inhibitors, and several mediate serotonin reuptake inhibition as well.
Additional Medications Hydroxyzine Atarax, Pfizer , mirtazapine Remeron, Organon , nefazodone Bristol-Myers Squibb , and atypical neuroleptic agents are commonly used to treat anxiety. Side Effect Profiles Patients and physicians need to be aware of adverse drug reactions. Cognitive—Behavioral Therapy and Medications CBT has received the greatest amount of empirical support for the psychological treatment of anxiety disorders.
Cognitive—Behavior Therapy Alone It is generally acknowledged that the treatment of anxiety disorders is suboptimal because of a lack of CBT therapists or the availability of affordable sessions. Technique CBT shares much in common with other more dynamically based forms of psychotherapy. Exposure Exposure is the gradual and systematic presentation of the anxiety-inducing thought, image, or situation for a long enough time for patients to see that their anxious feelings can be decreased without engaging in avoidance or escape.
This is a mixed blessing for several reasons: SSRIs are often prescribed quickly in response to emotional distress that might not meet criteria for an anxiety disorder. Adverse effects might not be managed by any means other than by discontinuation of the treatment. Management of Treatment-Resistant Anxiety In managing refractory anxiety, it is important to start with a re-evaluation of the patient, including the diagnosis; comorbidities; and the interplay of cognitive, stress-related, and biological factors.
Experimental and Off-Label Nonpharmacological Treatments Therapies for anxiety disorders, beyond combining conventional treatments, using off-label antiepileptic and antipsychotic agents, and introducing more intensive CBT programs, are mostly experimental. Electroconvulsive Therapy Electroconvulsive therapy ECT involves the application of brief electrical impulses to the scalp to induce large-scale cortical neuronal discharges, eventually producing generalized seizure activity.
Vagal Nerve Stimulation Initially developed as an antiepileptic treatment, vagal nerve stimulation VNS was used in psychiatric patients after sustained mood improvements were noted with this therapy.
She may run tests to rule out medical illnesses that might be causing your symptoms. No lab tests can specifically diagnose anxiety disorders. Diagnosing GAD and PD requires a broad differential and caution to identify confounding variables and comorbid conditions. Screening and. For instance, in patients with some disorders such as generalized anxiety disorder (GAD) and social anxiety disorder.